Abdominal Aortic Aneurysm Abdominal Aortic Aneurysm David N. Duddleston, MD David N. Duddleston, MD VP and Medical Director VP and Medical Director Southern Farm Bureau Life Southern Farm Bureau Life Jackson, Mississippi Jackson, Mississippi A Case A Case Ms. Ms. Ima Ima Bolgin Bolgin, age 54, $1.2 million, sent to you , age 54, $1.2 million, sent to you for review. Smoker, ½ pack per day for review. Smoker, ½ pack per day 2011 2011 - - Incidental 3.8 cm abdominal aortic Incidental 3.8 cm abdominal aortic aneurysm per CT in emergency department aneurysm per CT in emergency department (abdominal pain), one year follow- -up is 4.0 cm up is 4.0 cm (abdominal pain), one year follow Cholesterol controlled on statin x 5 years Cholesterol controlled on statin x 5 years Mild diabetes, glycohemoglobin of 6.8 Mild diabetes, glycohemoglobin of 6.8 Normal EKG, history & exam Normal EKG, history & exam Assess the risk! Assess the risk! 1
Abdominal Aortic Aneurysm Abdominal Aortic Aneurysm AAA in Context AAA in Context Defined as aortic dilation 1.5x the diameter Defined as aortic dilation 1.5x the diameter of the adjacent normal aorta, at the level of of the adjacent normal aorta, at the level of the renal arteries, translating to >3.0 cm the renal arteries, translating to >3.0 cm Related to, but likely not caused by Related to, but likely not caused by atherosclerosis atherosclerosis Inflammatory component Inflammatory component th leading cause of death in USA 13 th leading cause of death in USA 13 Abdominal Aortic Aneurysm Abdominal Aortic Aneurysm AAA in Context AAA in Context Now treated with surgical resection or Now treated with surgical resection or endovascular sleeve endovascular sleeve Rupture based on size, rate of enlargement Rupture based on size, rate of enlargement Rupture = Death in ~80% Rupture = Death in ~80% All cause mortality related to aneurysmal All cause mortality related to aneurysmal rupture, perioperative death and personal rupture, perioperative death and personal comorbidities comorbidities Interestingly, diabetes does not seem to Interestingly, diabetes does not seem to contribute to rupture contribute to rupture 2
Rupture Risk Based on Size Rupture Risk Based on Size < 4.0 cm < 4.0 cm – – 0% per year 0% per year 4.0- -4.9 cm 4.9 cm – – 0.5 0.5- -5% per year 5% per year 4.0 *5.0 5.0- -5.9 cm 5.9 cm - - 3 3- -15% per year 15% per year * 6.0- -6.9 cm 6.9 cm – – 10 10- -20% per year 20% per year 6.0 7.0 7.0- -7.9 cm 7.9 cm – – 20 20- -40% per year 40% per year >8 cm – >8 cm – 30- 30 -50% per year 50% per year * cutoff for intervention * cutoff for intervention Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery 3
Aneurysm Growth Aneurysm Growth Rate of expansion is usually about 0.5 cm Rate of expansion is usually about 0.5 cm per year, and an increase of 0.5 cm over 6 per year, and an increase of 0.5 cm over 6 months is considered important months is considered important Rapid expansion is an indication for repair Rapid expansion is an indication for repair Risk Factors for AAA Risk Factors for AAA Smoking Smoking Gender (men 4x more likely to have Gender (men 4x more likely to have AAA) AAA) Age >65 Age >65 Uncontrolled hypertension Uncontrolled hypertension 4
More AAA cases - - Screening Screening More AAA cases Recommendations for AAA Recommendations for AAA The US Preventive Services Task Force The US Preventive Services Task Force (USPSTF) recommends a one- (USPSTF) recommends a one -time time ultrasound screening for AAA in men ultrasound screening for AAA in men between 65 and 74 years of age who have between 65 and 74 years of age who have ever smoked. The USPSTF advises ever smoked. The USPSTF advises against routine screening in women and against routine screening in women and concludes that insufficient evidence exists concludes that insufficient evidence exists to advocate for or against routine to advocate for or against routine screening in men 65 to 74 years who have screening in men 65 to 74 years who have never smoked. never smoked. More AAA cases More AAA cases Most emergency departments in the US Most emergency departments in the US have a CT scanner within the department, have a CT scanner within the department, resulting in many more AAAs being found resulting in many more AAAs being found incidentally incidentally Number of CT scans completed has tripled Number of CT scans completed has tripled within the past 15 years within the past 15 years 5
Treatment Available for AAA Treatment Available for AAA The UK EndoVascular EndoVascular Aneurysm Repair Aneurysm Repair The UK (EVAR) trials: (EVAR) trials: randomised randomised trials of EVAR trials of EVAR versus standard therapy. versus standard therapy. – Health Technology Assessment 2012, – Health Technology Assessment 2012, http://www.hta.ac.uk/fullmono/mon1609.pdf http://www.hta.ac.uk/fullmono/mon1609.pdf Open Repair Open Repair – – 30 day mortality ~4% 30 day mortality ~4% EVAR – – 30 day mortality ~2% 30 day mortality ~2% EVAR Smoking cessation, blood pressure control Smoking cessation, blood pressure control reduces risk of rupture reduces risk of rupture EVAR vs. Open Repair EVAR vs. Open Repair JAMA April 18, 2012 JAMA April 18, 2012 6
Morbidity and Mortality by Aortic Morbidity and Mortality by Aortic Size Size Long term outcomes in men screened Long term outcomes in men screened for abdominal aortic aneurysm: for abdominal aortic aneurysm: prospective cohort study prospective cohort study – BJM, May 2012 – BJM, May 2012 Scottish men screened for AAA 2001 Scottish men screened for AAA 2001- - 2004, followed into 2010 2004, followed into 2010 Hospitalized for a Circulatory Event Hospitalized for a Circulatory Event 7
Hospitalized for the Aneurysm Hospitalized for the Aneurysm Overall Mortality with AAA Overall Mortality with AAA Mortality most significant in men > 65 Mortality most significant in men > 65 years years Aneurysmal Death 20x (repair mitigates Aneurysmal Death 20x (repair mitigates this) this) Cancer 3x Cancer 3x Other vascular disease 2x Other vascular disease 2x All cause 2x All cause 2x BMJ, May 4, 2012 8
Similar Death Rates in US study Similar Death Rates in US study Men Women Cardiovascular Disease and Mortality in Older Adults with Small Abdominal Aortic Aneurysms Detected by Ultrasonography: The Cardiovascular Health Study . Annals of Int Med 6 February 2001 Mortality After Repair Mortality After Repair Comparison of Long- -term Survival term Survival Comparison of Long After Open vs vs Endovascular Repair of Endovascular Repair of After Open Intact Abdominal Aortic Aneurysm Intact Abdominal Aortic Aneurysm Among Medicare Beneficiaries - - JAMA JAMA Among Medicare Beneficiaries 9
Similar Mortality After Recovery Similar Mortality After Recovery 10
AAA Underwriter’s Pain Scale AAA Underwriter’s Pain Scale As aortic size increases, the underwriter must consider rate of progression, considerations and risks for intervention. The larger the aneurysm, the more discomfort the underwriter feels. Underwriting Considerations Underwriting Considerations Use the Underwriter’s Pain Scale! (just Use the Underwriter’s Pain Scale! (just kidding) kidding) High risk of intervention High risk of intervention Review other cardiovascular risk factors Review other cardiovascular risk factors Check for COPD Check for COPD 11
Our Case Our Case For For Ima Ima Bolgin Bolgin: : – AAA: when could you expect her to need AAA: when could you expect her to need – intervention? intervention? – Tobacco affects rate of expansion Tobacco affects rate of expansion – – Diabetes control as part of overall risk Diabetes control as part of overall risk – – Base risk is about 2x – Base risk is about 2x Thank You! Thank You! 12
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